ESBD_524136_1780667799666_10. Exhibit J.11 - TDCJ Non-Employee Background Questionnaire.pdf

PERS 263 (06/10/19) Page 1 of 3

Texas Department of Criminal Justice Non-Employee Background Questionnaire

This information is needed for the TDCJ to conduct a criminal history check to determine whether access to TDCJ units and departments should be approved. All questions shall be answered in full.

NOTE TO APPLICANT: With few exceptions, you are entitled upon request: (1) to be informed about the information the TDCJ collects about you; and

(2) under Texas Government Code §§ 552.021 and 552.023, to receive and review the collected information. Under Texas Government Code § 559.004, you are also entitled to request, in accordance with TDCJ procedures, that incorrect information the TDCJ has collected about you be corrected.

1. Name: 2. Social Security No.:

Last First Middle

(As it appears on your Social Security Card)

3. Mailing Address:

Street City State Zip

4. Date of Birth: 5. Place of Birth:

(MM/DD/YYYY) City State

6. Driver License No.: State: 7. Phone No.: ( )

8. Other names used (maiden, alias, nicknames):

9. Sex: Male Female 10. E-mail Address:

11. Ethnic Origin: White Black Hispanic Asian/Pac. Islander Am. Ind/Alaskan Other

12a. Have you previously been employed by the TDCJ or worked in a TDCJ facility on a contract basis? Yes No If yes, give unit(s)/department(s), position(s) held, and dates:

12b. Have you engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution?

Yes No

12c. Have you been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse? Yes No

12d. Have you been civilly or administratively adjudicated to have engaged in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse? Yes No

12e. Have you been involved in any substantiated incidents of sexual harassment? Yes No If yes, please explain:

13. Are you related to any employee or contract employee of the TDCJ? Yes No Unknown If yes, list name, relationship, and unit/department of assignment:

14a. Are you or any immediate member of your family (to include, but not limited to parent, brother, sister, spouse, or child) related to a current or former TDCJ offender (incarcerated or on parole)? Yes No Unknown If yes, provide the name of the offender(s):

14b. Are you now or have you ever been involved in a spousal relationship with a current or former TDCJ offender (incarcerated or on parole)?

This includes marriage, common-law marriage, lived together, or had a child together. Yes No If yes, provide the name of the offender(s):

14c. Do you have a current business partnership or gang association with a current or former TDCJ offender (incarcerated or on parole)?

Yes No Unknown If yes, provide the name of the offender(s):

14d. Are you on a current TDCJ offender’s visitation list? Yes No If yes, provide the name of the offender(s):

14e. Have you corresponded in the last year with a current TDCJ offender? Yes No If yes, provide the name of the offender(s):

NOTE:

• If you answered yes to Question 14a, b, c, d, or e above, you are required to complete and submit a PERS 282A, Additional

Offender Information. The PERS 282A form is available from the TDCJ website at www.tdcj.texas.gov.

• If you have a personal relationship with an offender who is not a relative, be sure to read the “Offender Relationships” paragraph on Page

3 of this questionnaire.

(Continued on Page 2)

Solicitation Number: IW247306 Exhibit J.11

PERS 263 (06/10/19) Page 2 of 3

IMPORTANT

Read the definition of conviction in Question 17. When answering questions 15 through 17, do not include: 1) any violation of law committed before your 17th birthday if the final decision was made in juvenile court or under a youth offender law; 2) any conviction whose record was expunged under federal or state law; 3) minor traffic violations. DWI, DUI, Open Container, and Driving While License Suspended are not minor traffic violations and shall be listed.

15. Do you have any criminal charges currently pending? Yes No If yes, please explain:

16. Are you on parole or probation, deferred adjudication, or under a pre-trial diversion agreement? Yes No If yes, please explain:

17. Have you ever been convicted of a crime (misdemeanor or felony)? Yes No If yes, list each one below.

Attach an additional page if necessary. Include those that may not appear on your record at this time.

Important: For purposes of contract employment with the TDCJ, convictions include sentenced to confinement, paid fine, time served, placed on probation (includes deferred adjudication), and court ordered restitution. See Falsification Policy on Page 3 of this questionnaire.

Date Felony or Misdemeanor Offense

Offense Class City & State Punishment

DOCUMENT REQUIREMENTS: You are required to provide with this questionnaire a disposition for each criminal charge you reported in Questions 15, 16, and 17 above. A disposition is a statement of the charge, date, and the results of the case. If the charge was dismissed, the disposition shall state the reason for dismissal. Dispositions can normally be obtained from the clerk of the court having jurisdiction over the case.

18. Are you now or have you ever been a member of a street gang? Yes No

Are you now or have you ever been a member of or affiliated with an organization promoting racial, ethnic, or gender superiority or separation, independence from governmental laws and regulations, or overthrow of the United States Government?

Yes No

If you answered yes to either of these questions, provide the following information:

a. Name of the organization and dates of membership:

b. Position or positions you held in the organization:

c. Arrests and/or convictions resulting from your activities as a member:

19. Do you have any tattoos or markings on your body signifying membership or affiliation with a street gang or associated with organizations promoting racial, ethnic, or gender superiority or separation, independence from governmental laws and regulations, or overthrow of the United States Government? Yes No

If yes, provide a description and location of those tattoos or markings:

(Continued on Page 3)

PERS 263 (06/10/19) Page 3 of 3

FALSIFICATION POLICY

It is important that contract employee applicants provide accurate information in this questionnaire. Failure to list any criminal conviction or other important information, such as prior employment with the TDCJ or offender relationships, is considered falsification of the questionnaire and results in disqualification for contract employment access to TDCJ facilities for one year.

As a criminal justice agency, it is very important for the TDCJ to know if an applicant has a criminal record. In most cases, a criminal record does not disqualify you from access to TDCJ facilities. However, falsification of the questionnaire always disqualifies you, regardless of how well qualified you are otherwise.

What convictions shall be listed? All convictions handled in adult court shall be listed, no matter when or where they occurred. In Texas, if you are 17 years old or older, the case is always handled in adult court. If you are under 17, it still may be handled in adult court. As an exception, you are not required to list convictions for minor traffic violations. Examples of minor traffic violations are speeding, running stop signs, and no seat belts. Examples of crimes which are not minor traffic violations and shall be listed are DWI, DUI, Leaving the Scene of an Accident, Assault with a Motor Vehicle, Reckless Driving, Open Container, and Driving While License is Suspended. Convictions that have been expunged under state or federal law do not have to be listed. Expunged means a judge signed an order directing all agencies with a record of the arrest and conviction destroy those records (this is not the same as a deferred adjudication, explained below).

What is a conviction? For TDCJ purposes, a conviction is (a) a finding of guilt by judge or jury and the assessment of punishment, whether confinement or fines; (b) community supervision (probation), including deferred adjudication; (c) a juvenile adjudication of delinquent conduct if the juvenile records are not sealed; and (d) an equivalent disposition of an offense under the laws of another state, federal law, or Uniform Code of Military Justice. The term does not include a pretrial diversion, which is an agreement between the defendant and prosecutor and occurs before a judicial finding, although a judge may approve of the defendant participating in the program. Pardons or reprieves do not eliminate a conviction. If you have a case handled by deferred adjudication, it shall be listed in your application, regardless of whether you think it is still on record.

Military Convictions. Convictions by court martial for criminal offenses shall also be listed.

Failure to Appear. If you were convicted of a routine traffic violation or other offense and did not pay the ticket on time or failed to appear to court, you may have been charged with and convicted of Failure to Appear. Failure to Appear is a separate crime and shall be listed.

Questions. If you have any questions concerning what shall be listed in this questionnaire, it is recommended you contact the Human Resources Division in Huntsville at (936) 437-3126 before you submit this questionnaire.

OFFENDER RELATIONSHIPS: TDCJ employees and contract employees with access to TDCJ facilities are prohibited from maintaining or developing a personal relationship with an offender who is not related to the employee. Prohibited relationships include those involving cohabitation, sexual misconduct, or actions that jeopardize or have the potential to jeopardize the security of the TDCJ.

This means employees and contract employees may not have personal contact or relationships with offenders currently incarcerated or on parole outside of their official duties if this contact or relationship would jeopardize or has the potential to jeopardize the security of the TDCJ. Prohibited contact includes living together, writing letters or notes, telephone contact, visitation, and depositing funds into an offender’s Inmate Trust Fund (ITF) account. If an employee or contract employee was once married to an offender or had a child together with an offender, employee contact with the offender may be limited to that which is ordered by the court. As a condition of contract employment with the TDCJ, contract employees with prohibited relationships shall sever those relationships. Sever means to cease any and all cohabitation, intimate encounters, verbal or written communications, visitation, or other prohibited contact.

Continuation of a prohibited relationship after contract employment with the TDCJ may result in denial of access to TDCJ facilities, if the TDCJ determines the relationship jeopardizes or has the potential to jeopardize the security of the TDCJ.

ADDITIONAL INFORMATION: All applicants, who may have contact with offenders, are ineligible for employment if they have committed any activity described in questions 12b, 12c, or 12d.

CERTIFICATION: I certify that I have read and understand the above explanation of the TDCJ Policy on Falsification and Offender Relationships. I further certify that my answers on this questionnaire are true, complete, and correct to the best of my knowledge and I have not evaded or omitted any part thereof to reflect an untruth. I understand falsification constitutes grounds for refusing or terminating access to TDCJ units and departments.

DUTY TO DISCLOSE: I hereby acknowledge that I have a duty to disclose any sexual misconduct during the term of my employment. I further acknowledge that I have a duty to disclose any misconduct on my part while working for previous employers.

Signature: _________________________________________ Date: _______________________

OFFENDER RELATIONSHIPS: TDCJ employees and contract employees with access to TDCJ facilities are prohibited from maintaining or developing a personal relationship with an offender who is not related to the employee. Prohibited relationships include t...